306006066-9-15-2022-22-AS-ETAA-CJAPEH-20220915111510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006066
Report Date: 09/15/2022
Date Signed: 09/15/2022 11:15:40 AM

Document Has Been Signed on 09/15/2022 11:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CALIFORNIA GUEST HOME		FACILITY NUMBER:	306006066
ADMINISTRATOR:	CELIS, PRISCILLA		FACILITY TYPE:	740
ADDRESS:	2840 E QUINCY AVE		TELEPHONE:	(562) 388-5088
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	6	CENSUS: 4	DATE:	09/15/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Arphie Tanedo, Marjorie Facienel, Priscella Celis, Liza Dela Cruz		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Edward Tapia made an unannounced required post-licensing inspection at this facility. LPA met with staff Arphie Tanedo and stated the purpose of this visit. Administrator Priscilla P Celis and Licensee Liza C Dela Cruz arrived after the inspection. The facility is a two-level structure licensed for six non-ambulatory with a hospice waiver for six. This facility offers Residential Care for the Elderly. At about 9:05 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 4 residents in care and 3 staff members on duty. LPA toured the interior and exterior portions of the facility. There were 4 resident rooms 1 of them was shared room and 1 was a vacant room. The facility also had staff rooms on the second floor which are inaccessible to residents. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 114.9 degrees Fahrenheit. LPA noticed water was slow to drain in restroom sink. Administrator was made aware of this and will have sink reviewed. For the exterior portion, furniture was in good repair; and grounds were free of tripping hazards. LPA noticed some debris and a jacuzzi in the backyard in a corner. LPA informed Administrator to removed debris and unused jacuzzi from facility. Facility offers a 2-car garage which is used for storage with an operational washer and dryer. Kitchen was in good repair with sharps and cleaning supplies kept locked. LPA was informed by staff that freezer in kitchen does not work. LPA informed Administrator to have freezer repaired. Administrator will have freezer repaired.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CALIFORNIA GUEST HOME	FACILITY NUMBER: 306006066
	VISIT DATE: 09/15/2022

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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, No deficiencies were noted in areas observed. One advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Priscilla P Celis and copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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